The Future Healthcare Today Podcast

On the Future Healthcare Today Podcast with Lucas Hunsicker, Kristin Gasteazoro, Senior Vice President of SmartShopper Sales and Client Performance at Zelis, and Reagan Greene, Vice President of Brand, Marketing, and Communications at Blue Cross of Idaho (BCI), dive into the significance of personalized messaging and care delivery strategies. In their discussion, they outline different tactics aimed at revolutionizing healthcare experiences, emphasizing the value of personalization and innovative approaches to cater to diverse consumer needs. Their insights shed light on the continuous efforts to improve healthcare accessibility and effectiveness by using digital tools and tailored communication strategies.

In the Future Healthcare Today Podcast, hosted by Lucas Hunsicker, featuring Kristin Gasteazoro, Senior Vice President, SmartShopper Sales and Client Performance at Zelis, and Reagan Greene, Vice President for Brand, Marketing and Communications at Blue Cross of Idaho (BCI), they focus on revolutionizing healthcare experiences and consumer engagement. During the podcast, Kristin emphasizes the importance of empowering members through strategic partnerships, addresses the resurgence in healthcare claims post-COVID, and highlights the industry’s response to escalating costs. This demonstrates a transformative move towards a more unified and meaningful member experience. Reagan explored the necessity of understanding consumer preferences in communication and media consumption, advocating for continuous support throughout the healthcare experience. Both guests stress the role of measuring outcomes and improving strategies to adapt to the evolving consumer behaviors and media landscapes.

Despite healthcare’s critical importance, the intricate nature of insurance plans and healthcare information can often leave individuals feeling adrift. A recent Bend Financial report found that 56 percent of respondents felt “completely lost” when trying to understand health insurance, with even higher rates among people on a family member’s job-based insurance (75 percent) or those on COBRA (68 percent). The solution? Engagement. In this episode of the Future Healthcare Today podcast, host Lucas Hunsicker engages in a discussion with Rousseau Kluever, Director of Product, Healthcare Guidance, at Zelis, to explore innovative strategies for bolstering meaningful member engagement. From personalized solutions, which incentivize proactive health actions, to the importance of an omni-channel strategy that meets members where they are, Kluever emphasized the necessity of a member-centric approach. By prioritizing personalization and accessibility, he explained how healthcare organizations can empower individuals to focus on their health goals without the burden of navigating the complexities alone. As the conversation unfolds, it is evident that the future of healthcare lies in these personalized experiences, seamless interactions, and genuine support for members. By embracing innovative approaches and leveraging technology to its fullest potential, healthcare organizations can foster deeper connections with their members and ultimately enhance the quality of care delivered.

Despite healthcare’s critical importance, the intricate nature of insurance plans and healthcare information can often leave individuals feeling adrift. A recent Bend Financial report found that 56 percent of respondents felt “completely lost” when trying to understand health insurance, with even higher rates among people on a family member’s job-based insurance (75 percent) or those on COBRA (68 percent). The solution? Engagement. In this episode of the Future Healthcare Today podcast, host Lucas Hunsicker engages in a discussion with Rousseau Kluever, Director of Product, Healthcare Guidance, at Zelis, to explore innovative strategies for bolstering meaningful member engagement. From personalized solutions, which incentivize proactive health actions, to the importance of an omni-channel strategy that meets members where they are, Kluever emphasized the necessity of a member-centric approach. By prioritizing personalization and accessibility, he explained how healthcare organizations can empower individuals to focus on their health goals without the burden of navigating the complexities alone. As the conversation unfolds, it is evident that the future of healthcare lies in these personalized experiences, seamless interactions, and genuine support for members. By embracing innovative approaches and leveraging technology to its fullest potential, healthcare organizations can foster deeper connections with their members and ultimately enhance the quality of care delivered.

People often turn to family, friends, and Google to make healthcare decisions and find healthcare providers. This can lead to confusion and misinformed decisions. Healthcare partners can – and should - step in and offer solutions that simplify this process and provide knowledgeable information. For example, care guidance tools can make the care selection process simpler for members. Healthcare partners provide services that enable people to receive high-quality care. These omni-channel solutions assist members by meeting them where they are, whether through preventative care or other programs, and by helping members make timely and appropriate healthcare decisions based on their age, gender, and other demographics. Additionally, care guidance solutions can close care gaps by motivating members to see a doctor and reducing barriers to care. With the mission to ensure a healthier population while increasing member engagement and satisfaction, healthcare partners can improve the care experience for members. These were the key themes of the latest Future Healthcare Today podcast, where Kristin Gasteazoro, SVP, SmartShopper Sales and Client Performance at Zelis, discussed care guidance tools and omni-channel solutions for improving member engagement.

The Affordable Care Act, far from simplifying healthcare, has introduced many more complexities, making the jobs of HR workers even more challenging as they attempt to keep pace with the fast-changing regulatory environment. This has created the opportunity for healthcare brokers to step in to fill knowledge gaps and extend the value of the HR team. In the highly competitive market, brokers need to be equipped with innovative technology and data capabilities to be successful. Their expertise in understanding evolving regulations enables brokers to help navigate the complexities of benefits and forge stronger relationships with clients. Brokers uncover network gaps and facilitate comparisons with competitor network performance leading to actionable insights. Moreover, these experts improve time management, facilitate better decision-making for insurers, and deliver cost savings with programs such as SmartShopper. These were the key themes of our recent Future Healthcare Today podcast about the broker space and how brokers can partner with employer groups to build strong client relationships. Host Lucas Hunsicker talked with Rob Graybill, Senior Vice President, Strategy & Business Development at Zelis, and explored the healthcare environment and how innovative solutions with advanced analytics are helping client connections.

The Transparency in Coverage (TiC) regulations provide further clarification for the use of Machine-Readable Files (MRFs) for the health insurance industry. These rules require that healthcare plans and issuers offering health insurance coverage in individual and group markets disclose in-network provider-negotiated rates through MRFs. The outcome will be increased data transparency for payers, providers, and members and improved accessibility and usability for member-facing transparency tools. One of the challenges with MRF files is that they are typically very large and require significant computing power to download, which makes it difficult for members to access them. To overcome this challenge third-party tools have been developed that provide an infrastructure to host the data so that it can be readily available. Both payers and providers can use the payer rate data to evaluate their competitive pricing position and improve provider contracting efforts. These were the key themes of our recent Future Healthcare Today podcast about how TiC regulations have affected the use of MRFs. Host, Lucas Hunsicker, talked with Dennis Charland, Senior Vice President, Transparency and DaaS Sales at Zelis, about the recent release of MRF rate-based files and how they will change the market.

The healthcare industry has seen its fair share of disruptions in the last few years. With the advent of telehealth and a renewed interest in taking charge of their healthcare, many members have interacted with their plans like never before. However, new interactions can lead to increased expectations for the future of healthcare Zelis conducted a study to discover how satisfied members are with their healthcare journey. The results included pits and peaks, each revealing another new and important consideration for payers. However, common needs emerged. Members expressed the need for more clarity, control, and guidance on their healthcare journey. These three concepts emerged for good reason as each provides a member with the ability to take a more active role in their healthcare journey. Further, it allows members to make more informed decisions about their health. But what does this mean for payers looking to bolster their relationship with their members? How can they bring clarity, control, and guidance to the forefront of their solutions? What do those three aspects look like in terms of on-the-ground experiences? To unpack and better explain these questions, Future Healthcare Today spoke with Madison Goldfischer, Vice President and Head of Product for Member Empowerment at Zelis, to find out more. This latest podcast dives into the specifics of the recent Member Empowerment Survey, what members expect when dealing with their partners, and how healthcare can learn from other industries with a customer-focused mindset.

Previously, on the Future Healthcare Today Podcast, we heard from Mary Piecuch, Senior Vice President of Product Strategy, and Erick Russell, Director of Network Operations, both at Zelis, about the basics of a reference-based pricing model and what payers, providers, and members need to know to make the most of the solutions and how it can to beneift the patient experience. However, when the conversation turned to the benefits that come from embracing RBP, the conversation lasted far longer than we expected. As such, we decided to reconvene later with our subject-matter experts to dive deeper into the myriad benefits that come from properly using a reference-based pricing model. Ranging from cost-conscious decision-making ability to the freedom to treat patients without fear of a long or arduous payment process, there are many ways that payers, providers, and members all benefit under an RBP model. Benefits can be realized as soon as the model is embraced, but both Mary and Erick expressed that there was something else that was more exciting to them. Beyond just the benefits in the immediate term, Mary and Erick shared some of their thoughts on the future of RBP models, and how Zelis’ recent acquisition of Payer Compass will impact the future of reference-based pricing. There is good reason to expect continued investment and innovation around the model, but what does that mean for those interested?

It should come as no surprise that recent events around the world have created an atmosphere of change almost everywhere. People are living radically different lives than they were three years ago, and with those changes comes a desire for the services they use to keep up with their lifestyles. In this environment, it seems almost inevitable that something like the reference-based pricing model for healthcare would emerge as a much-needed solution to modern issues. A reference-based price model, in short, gives patients and payers a way to ensure adequate healthcare is administered, paid for, and covered while avoiding staggering provider contract fees or out-of-network prices. RBP can be used in several ways, including as a full network replacement, as support for out-of-network savings, narrow networks, or even custom network build options. This is largely thanks to the aforementioned open access to providers and zero network limitations, which allows members to make informed provider decisions that align with their personal preferences. Additionally, RBP helps providers make sure that if someone comes in needing assistance, they can administer care without the worry of a long and arduous arbitration process if the patient is not an in-network member. To better explain the concept, and to offer additional context as to the benefits of RBP, Mary Piecuch, Senior Vice President of Product Strategy and Erick Russell, Director of Network Operations, both at Zelis, joined the latest installment of the Future Healthcare Today podcast.

In a previous episode of the Future Healthcare Today Podcast, the editorial team heard from three healthcare network solutions experts at Zelis about how payers can create and maintain a robust collection of providers and the benefits that this brings. However, the relationship is a two-way street, as there are many tangible benefits to joining a provider network that accrue to the provider as well. One of the most important benefits according to Tammie Skiles, Senior Vice President for Network Solutions at Zelis, is the predictability that comes from being part of a network. “Contracts are negotiated so everyone understands the agreement for services, fees, and schedule rates,” she told Future Healthcare Today. Additionally, there is an expectation that being in-network creates an easier path for patients to find a provider that will meet their needs. “As a provider, you really are looking for a partner who can steer members to your office, or chair as we say in dental,” Kim Sharbatz, Senior Director for Strategic Network Partnerships said. Ideally, an effective provider network ensures providers have few, if any, gaps in their schedule. Finally, as Robin Marino, Director for the Zelis Dental Network said, providers can also get further benefits through access to major carriers and TPAs. “It’s a big reason providers approach [companies like Zelis], you sign one contract and gain an opportunity to reach many members and can save time with compliance, network needs, and credentialing.” As providers navigate the next generation of healthcare needs and trends changing the industry, being a part of an established provider network affords the ability to thrive.

The healthcare network, made up of providers and managed by payers, is one of the most important aspects of the entire industry. It forms the foundation upon which patients base their expectations, the primary component which payers use to attract members, and that providers use to ensure visibility among patient populations looking for services. However, recent events have fundamentally altered the way all three use networks. To better understand the many changes that the healthcare network is experiencing and what these changes mean for building a robust payer network, Future Healthcare Today spoke with three network solutions experts from Zelis. “Member needs are changing,” Robin Marino, Director for the Zelis Dental Network said. Marino mentioned that trends like “dispersed workforces, work from home, new technology, all these combined with an evolving set of expectations from patients mean that payer networks need to change to keep up and remain competitive.” “[Building a competitive network] requires an understanding of patient needs, provider demographics, and geographic areas,” Tammie Skiles, Senior Vice President for Network Solutions, explained. “[Together these, among other variables] are how we define competitiveness of a network, and payer networks need to be competitive to be successful.” Frequently, however, health plans lack the resources to best track changes that impact their networks’ competitiveness. “If a health plan does have a network, it often isn’t their primary focus,” Kim Sharbatz, Senior Director for Strategic Network Partnerships, said. “They are more focused on growing their product ...making it tough for network areas to battle for resources.” This can be a problem for payers when their network is not keeping pace with the evolution of the healthcare industry. With payer networks at a crossroads and no sign of the pace of change slowing, Future Healthcare Today shares how to build a robust network and how to ensure its success for years to come.

Third-Party Administrators (TPAs) and health plans have many things in common, but one that stands out is the challenge both are facing in today’s healthcare industry. With digital transformation, ongoing demographic shifts, and a variety of other long and short-term trends, TPAs and health plans are facing significant headwinds when it comes to creating a modern healthcare network. Despite these challenges, there are many ways for TPAs and health plans to create competitive, cost-effective, and compliant networks. “Meeting member needs, and by extension reducing member abrasion, is one of the industry’s largest challenges,” said Maisie Weir, Director of Business Solutions. Weir noted that Zelis has found that by empowering health plans and TPAs to build, access, and manage networks it is possible to reduce pressure around resource constraints, and ultimately create high-performing network solutions. Erick Russel, Director of Network Operations at Zelis added that among the specific issues facing TPAs, finding ways to deliver value and creating access to strong networks is key to thriving in the modern healthcare network ecosystem. Russel added that “TPAs also need to be aware of how provider pricing variability has had a major impact on driving up traditional healthcare costs.” Payers have been searching for new strategies to help stabilize claim costs, Russell added. Indeed, his team at Zelis has seen an increase in the need for network replacement solutions, which he noted often included some form of reference-based pricing. But apart from the more industry-specific trends driving change, Kim Sharbatz, Senior Director of Strategic Network Partnerships, pointed to an overarching trend that is having an outsized impact on the industry. “We’ve said it time and time again, but in today’s world everything is virtual,” Sharbatz told FHT. “That means our workforces must become virtual as well.” This evolution has created challenges for health plans and TPAs because memberships have become widely dispersed which can make it difficult to build and manage network solutions to fulfill their access for their members. Sharbatz argued that creating a modern healthcare network requires a health plan or TPA to dedicate a large number of its resources to really understand networks and the market, or alternatively “they can work with a partner who already does all that and more.”

Accessibility and adequacy are two of the most important elements for healthcare plans today, and digital transformation has made both easier to track and provide. At their core, accessibility and adequacy revolve around the expectation that a health plan member can find not only the right healthcare provider for their needs but that they can do so easily. Being able to easily find the right healthcare provider has become a challenge for many people, due in no small part to the COVID-19 pandemic. Not only did populations shift, with many people leaving larger, more centralized locations in favor of more rural areas, but also because medical practitioners left the field. Despite the disruptions and changes resulting from COVID-19, patient expectations for their healthcare plans did not change, and many health plans found themselves scrambling to ensure adequate and accessible healthcare solutions were available in more places than ever before. How did plans adapt? Has the importance of both accessibility and adequacy remained? What should health plans do to better assess their networks for both? In the latest edition of the Future Healthcare Today podcast, Jillian Carlile, Senior Product Analyst for Network Solutions, and Paul Nance, Senior Product Analyst for Network Analytics, both from Zelis, share their thoughts on the enduring importance of both and what companies like Zelis can do to help plans meet and exceed expectations:

In the healthcare industry, a network is only as strong as its providers. As the frontline of care, providers must be ready, able, and willing to help patients as effectively as possible, and while there is no doubt that most, if not all providers, seek to be the best they can be there are times when one provider is better suited to respond over another. But what should networks do when choosing healthcare providers? For a healthcare network, understanding the strengths of each provider, coupled with an understanding of what the member needs, is the most important aspect of their job. But what matters when reviewing a provider? What considerations must be taken into account? Where can providers' metrics be seen and compared? To answer these questions and many more, Future Healthcare Today spoke with Paul Nance Product Manager at Zelis, whose career has been dedicated to helping providers be as efficient and competitive as possible. According to Paul, often times the most important qualities to look for when choosing healthcare providers may not be the ones you expect.

In a previous conversation, Madison Goldfischer, Vice President and Head of Product for Member Empowerment at Zelis, joined Future Healthcare Today, to discuss the recently released member empowerment research report. In that conversation, Madison noted that while there were many areas that payers and providers can work to provide their members with more clarity, guidance, and control, one area that was worth investigating was the member journey. With lingering concerns about the COVID-19 pandemic, along with the lifestyle changes that accompanied it, many individuals are interacting with their providers like never before. As payers and providers look towards improving the experience, Madison encouraged both to look at what their journey looks like for a member, and to focus on ways the journey can be streamlined and made more efficient. From providing clearer indications and expectations about the total cost associated with care, to making the process of connecting with healthcare providers easier, there are many solutions that can make the member's journey much easier and more painless for the member. “The member experience has changed significantly over the past 10 years… the experience has really evolved from just engaging with your health plan for the purposes of talking about a claim to a lot more ongoing engagement opportunities… the boundary is going to be pushed on how both care delivery providers and care plans or health plans themselves are actually delivering solutions.”

The healthcare provider market has been in flux over the past few years with the challenges of the pandemic impacting healthcare operations among other trends. To help providers better understand and manage the challenges of this uncertain environment, there are important trends to be aware of, like growth in providers contracting with managed care plans across the market segments. Additional findings from the recently released State of the Provider Network Market Report 2022 suggest there is a positive growth in new hospitals, with micro-hospitals in satellite locations being of particular interest. These have primarily opened in more rural areas and demonstrate a larger shift towards more accessibility for traditionally less serviced communities. Conversely, there is an increase in providers, but out of approximately 10,000 new providers, only two percent were in rural locations. These were the key themes discussed in the recent Future Healthcare Today podcast with Jillian Carlile, Senior Product Analyst at Zelis. Carlile provided insight into the current state of the healthcare provider market and the ongoing changing impacting it.

On January 1, 2022, the No Surprises Act took effect to protect patients from surprise medical expenses, but it has created tension between payers and providers. For example, on February 23, 2022, the U.S. District Court for the Eastern District of Texas struck down the part of the interagency interim final rule implementing the “independent dispute resolution” (IDR) procedures. When payers and out-of-network providers cannot agree on reimbursement, either party can choose to initiate an IDR. While the majority of the rule remains in effect, the changes from this case will impact health plans and the insurers that sponsor them. These were the key themes of a recent Future Healthcare Today podcast interview with Matthew Albright, Chief Legislative Affairs Officer at Zelis, and Cate Brantley, Legislative Analyst at Zelis, who provided a deep-dive perspective on the IDR process and its impact on health payers.

As 2021 draws to a close, transparency is one of the biggest conversations for health payers. In 2022, some requirements of the No Surprises Act and Transparency in Coverage Rule come into effect. As payers prepare to meet regulatory deadlines – both near term and those further out – it’s understandable that they might have questions they need answered. Both of these regulations are broad and far-reaching, and will have an impact on overall healthcare costs, as well as the contracted rates for payers. In addition, while many payers have already invested a significant amount of money for meeting these mandates, there’s much more than can be done today. These were the key themes of this Future Healthcare Today podcast, titled, “Transparency in Coverage: Helping Health Payers Understand the Final Rule,” with Dennis Charland, SVP of Sales at Sapphire Digital, which was recently acquired by Zelis. Charland has previous sales experience Blue Cross Blue Shield of Massachusetts, and provided a closer look at what Transparency in Coverage means for payers, and explored solutions that can help ensure compliance for both upcoming mandates.

The No Surprises Act was designed to protect healthcare consumers against surprise billing. For payers, it has made processes more complex, especially relating to ensuring that reasonable and acceptable reimbursements are established and benchmarked by procedure, by provider, and by geography. On September 30, 2021, the Department of Health and Human Services, the Department of Labor, and the Department of the Treasury along with the Office of Personnel Management released an interim final rule, which further explains requirements related to the Independent Dispute Resolution (IDR) process and Qualified Payment Amounts. Greg Tackett, Senior Vice President of National Accounts and Strategy at Zelis, joined our Future Healthcare Today podcast to further explore these new rules and how median in network solutions can help ensure reasonable and acceptable reimbursements. “When payers who are not used to going through arbitration today, or if they do go to arbitration, it's on a very small amount of claims, they're going to need help and support to put the best argument forward on why what they have paid the provider is fair and reasonable, because providers will probably push back on what they're paid,” said Tackett.